A realistic evaluation : the case of protocol-based care

Background 'Protocol based care' was envisioned by policy makers as a mechanism for delivering on the service improvement agenda in England. Realistic evaluation is an increasingly popular approach, but few published examples exist, particularly in implementation research. To fill this gap, within this paper we describe the application of a realistic evaluation approach to the study of protocol-based care, whilst sharing findings of relevance about standardising care through the use of protocols, guidelines, and pathways. Methods Situated between positivism and relativism, realistic evaluation is concerned with the identification of underlying causal mechanisms, how they work, and under what conditions. Fundamentally it focuses attention on finding out what works, for whom, how, and in what circumstances. Results In this research, we were interested in understanding the relationships between the type and nature of particular approaches to protocol-based care (mechanisms), within different clinical settings (context), and what impacts this resulted in (outcomes). An evidence review using the principles of realist synthesis resulted in a number of propositions, i.e., context, mechanism, and outcome threads (CMOs). These propositions were then 'tested' through multiple case studies, using multiple methods including non-participant observation, interviews, and document analysis through an iterative analysis process. The initial propositions (conjectured CMOs) only partially corresponded to the findings that emerged during analysis. From the iterative analysis process of scrutinising mechanisms, context, and outcomes we were able to draw out some theoretically generalisable features about what works, for whom, how, and what circumstances in relation to the use of standardised care approaches (refined CMOs). Conclusions As one of the first studies to apply realistic evaluation in implementation research, it was a good fit, particularly given the growing emphasis on understanding how context influences evidence-based practice. The strengths and limitations of the approach are considered, including how to operationalise it and some of the challenges. This approach provided a useful interpretive framework with which to make sense of the multiple factors that were simultaneously at play and being observed through various data sources, and for developing explanatory theory about using standardised care approaches in practice

Part-time of what? Job quality and part-time employment in the legal profession in Australia

This article examines the quality of part-time employment for solicitors in private practice in Australia. Although full-time jobs based on long hours are dominant in the legal profession, part-time jobs

Cardio-protective effects of carnitine in streptozotocin-induced diabetic rats

BACKGROUND: Streptozotocin-induced diabetes (STZ-D) in rats has been associated with carnitine deficiency, bradycardia and left ventricular enlargement. AIM: The purpose of this study was to determine whether oral carnitine supplementation would normalize carnitine levels and cardiac function in STZ-D rats. METHODS: Wistar rats (48) were made hyperglycemic by STZ at 26 weeks of age. Same age normal Wistar rats (24) were used for comparison. Echocardiograms were performed at baseline 2, 6, 10, and 18 weeks after STZ administration in all animals. HbA1c, serum carnitine and free fatty acids (FFA) were measured at the same times. Since STZ-D rats become carnitine deficient, 15 STZ-D rats received supplemental oral carnitine for 16 weeks. RESULTS: The heart rates for the STZ-D rats (290 ± 19 bpm) were less than control rats (324 ± 20 bpm) (p < 0.05). After 4 weeks of oral carnitine supplementation, the serum carnitine and heart rates of the STZ-D rats returned to normal. Dobutamine stress increased the heart rates of all study animals, but the increase in STZ-D rats (141 ± 8 bpm) was greater than controls (79 ± 8 bpm) (p < 0.05). The heart rates of STZ-D rats given oral carnitine, however, were no different than controls (94 ± 9 bpm). The left ventricular mass/body weight ratio (LVM/BW) in the diabetic animals (2.7 ± 0.5) was greater than control animals (2.2 ± 0.3) (p < 0.05) after 18 weeks of diabetes. In contrast, the LVM/BW (2.3 ± .2) of the STZ-D animals receiving supplemental carnitine was the same as the control animals at 18 weeks. CONCLUSION: Thus, supplemental oral carnitine in STZ-D rats normalized serum carnitine, heart rate regulation and left ventricular size. These findings suggest a metabolic mechanism for the cardiac dysfunction noted in this diabetic animal model

Decentralised Learning MACs for Collision-free Access in WLANs

By combining the features of CSMA and TDMA, fully decentralised WLAN MAC schemes have recently been proposed that converge to collision-free schedules. In this paper we describe a MAC with optimal long-run throughput that is almost decentralised. We then design two \changed{schemes} that are practically realisable, decentralised approximations of this optimal scheme and operate with different amounts of sensing information. We achieve this by (1) introducing learning algorithms that can substantially speed up convergence to collision free operation; (2) developing a decentralised schedule length adaptation scheme that provides long-run fair (uniform) access to the medium while maintaining collision-free access for arbitrary numbers of stations

Teaching Addition to Students with Moderate Disabilities Using Video Prompting

Academic performance for students with moderate to severe disabilities falls far behind their typically developing peers and puts them at risk for continued dependence after school ends. Video prompting is an evidence-based practice that has been used to teach various non-academic skills; however, few studies have focused on using video prompting to teach academic skills other than reading. This study used a delayed multiple baseline across students design to evaluate the use of video prompting to teach single- and double-digit addition to three students with moderate disabilities. Results indicated that all three students improved their accurate completion of addition problems immediately upon introduction of the video prompting intervention. In addition, all three students completely faded the use of the videos and generalized completing addition problems to another setting. Social validity of the intervention was high across all participants, their families, and their teacher

Evidence for nodal superconductivity in LaFePO

In several iron-arsenide superconductors there is strong evidence for a fully gapped superconducting state consistent with either a conventional s-wave symmetry or an unusual $s_\pm$ state where there the gap changes sign between the electron and hole Fermi surface sheets. Here we report measurements of the penetration depth $\lambda(T)$ in very clean samples of the related iron-phosphide superconductor, LaFePO, at temperatures down to $\sim$ 100 mK. We find that $\lambda(T)$ varies almost perfectly linearly with $T$ strongly suggesting the presence of gap nodes in this compound. Taken together with other data, this suggests the gap function may not be generic to all pnictide superconductors

ELECTRONIC MARKETS AND ELECTRONIC HIERARCHIES: EFFECTS OF INFORMATION TECHNOLOGY ON MARKET STRUCTUR CORPORATE STRATEGIES

This paper analyzes the fundamental changes in market structures that may result from the increasing use of information teChnology. First, an analytic framework is presented and its usefulness is demonstrated in explaining several major historical changes in American business structures. Then, the framework is used to help explain how electronic markets and electronic hierarchies will allow closer integration of adjacent steps in the value-added chains of our economy. The most surprising prediction is that information technology will lead to an overall shift toward proportionately more coordination by markets rather than by internal decisions within firms. Finally, several examples of companies where these changes are already occurring are used to illustrate the likely paths by which new market structures will evolve and the ways in which individual companies can take advantage of these changes

Change of sagittal spinal alignment and its association with pain and function after lumbar surgery augmented with an interspinous implant

Background: Interspinous spacer/implants like the Device for Intervertebral Assisted Motion (DIAM™) are controversially yet commonly used in the surgical treatment of lumbar degenerative pathologies. Criticism is based on ill-defined indications, lack of superiority over decompression, and a poorly understood mechanical effect. Yet, continued use by surgeons implies their perceived clinical merit. We examined radiographic spinal alignment for 12 months, and pain and function for 24 months, after DIAM-augmented surgery to improve the understanding of the mechanical effect relating to clinical outcomes in patients. Methods: We undertook a single-surgeon prospective, longitudinal study of 40 patients (20 F, 20 M) who received DIAM-augmented surgery in treatment of their symptomatic lumbar degenerative condition. Outcomes measured included sagittal spinal alignment (lumbar lordosis, sacral inclination, primary (PDA), supradjacent (SDA) disc angles, and regional sagittal balance (RSB; standing lateral radiographs), and back and leg pain (visual analogue scale; VAS) and function (Oswestry Disability Index; ODI). Responders were identified as those with clinically meaningful improvement to pain (>20%) and function (>15%) at 24 months postoperatively; features of sagittal spinal alignment between responders and non-responders were examined. Results: Sagittal alignment was unchanged at 12 months. At 6 weeks postoperatively, PDA (mean (SD)) reduced by 2.2° (4.0°; p < 0.01) and more-so in back pain non-responders (3.8° (3.2°)) than responders (0.7° (4.4°); p < 0.05). Positive preoperative RSB in responders (26.7Rmm (42.3Rmm); Rmm is a system-relative measure) decreased at 6 weeks (by 3.1Rmm (9.1Rmm)). Non-responders had a negative RSB preoperatively (−1.0Rmm (32.0Rmm)) and increased at 6 weeks (11.2Rmm (15.5Rmm); p < 0.05). Clinically meaningful improvement for the whole cohort for back pain and function were observed to 24 months (back pain: 25.0% (28.0); function: 15.4% (17.6); both p < 0.0001). Conclusions: Unaltered sagittal alignment at 12 months was not related to symptoms after DIAM-augmented lumbar surgery. Subtle early flattening at the index disc angle was not maintained. Preoperative and early post-operative sagittal alignment may indicate response after DIAM-augmented surgery for mixed lumbar pathologies. Further investigation toward defining indications and patient suitability is warranted

Electron-impact excitation of X 1Sigma_g⁺(v[double-prime]=0) to the a[double-prime] 1Sigma_g⁺, b 1Piu, c3 1Piu, o3 1Piu, b[prime] 1Sigma_u⁺, c₄^[prime] 1Sigma_u⁺, G 3Piu, and F 3Piu states of molecular nitrogen

Measurements of differential cross sections (DCSs) for electron-impact excitation of the a[double-prime] 1Sigmag+, b 1Piu, c3 1Piu, o3 1Piu, b[prime] 1Sigmau+, c4[prime] 1Sigmau+, G 3Piu, and F 3Piu states in N2 from the X 1Sigmag+(v[double-prime]=0) ground level are presented. The DCSs were obtained from energy-loss spectra in the region of 12 to 13.82 eV measured at incident energies of 17.5, 20, 30, 50, and 100 eV and for scattering angles ranging from 2° to 130°. The analysis of the spectra follows a different algorithm from that employed in a previous study of N2 for the valence states [Khakoo et al. Phys. Rev. A 71, 062703 (2005)], since the 1Piu and 1Sigmau+ states form strongly interacting Rydberg-valence series. The results are compared with existing data